The ever-growing number of people with mental illness caught up in the
criminal justice system and different approaches to address that problem were
the focus of several articles in the June Psychiatric Services.
The series comes at a time when society has reached a "crisis
point" on the issue, according to John Talbott, M.D., the corresponding
author of a commentary in the journal on behalf of the Committee on Psychiatry
and the Community of the Group for the Advancement of Psychiatry (GAP).
Talbott is the former editor of Psychiatric Services and a former APA
Credit: Trista Weibell/istockphoto
The size and scope of the problem were clarified in a report by Henry
Steadman, Ph.D., Fred C. Osher, M.D., and colleagues (see
Education, Funding Crucial to
Reduce Number of Mentally Ill Inmates). The researchers concluded
that more than 2 million jail admissions of the total of 13 million in the 12
months ending by mid-year 2007 represented individuals with a serious mental
Those findings confirmed widespread fears that prisons and jails nationwide
have become de facto holding pens for the many Americans with mental
"It's worse and it's awful, but it's not new," Talbott told
The deepening recession and related budget deficits have led many state and
local governments to make deep cuts in their public mental health programs,
which in turn may be resulting in many more people with untreated psychiatric
conditions ending up in jails and prisons, according to Talbott. Moreover,
policymakers seem unable or unwilling to address the root causes of the
One of the strongest recent indicators of the extent of the problem came
when GAP requested that the "Dear Abby" advice columnist solicit
letters from people who had become entangled in the criminal justice system as
a result of their mental illness or their families.
GAP received nearly 3,000 letters, including one from a mother whose story
of her son's incarceration was retold in Psychiatric Services. The
mother, Carol Genengels, wrote that her son, John, became suicidal in 2002 so
she called her county mental health office for help. Police officers
responded, planning to take her son to a psychiatric hospital. After a brief
scuffle, John, who was in a confused state, was charged with assault and
jailed for several months. The extended jail time greatly worsened his mental
illness, and after his release John required inpatient treatment.
"This country desperately needs mental health reform where the
criminal justice system is concerned," Genengels wrote.
The letters revealed other powerful themes, Talbott noted in his GAP
committee commentary in Psychiatric Services. There were "many painful
stories of men and women with complex co-occurring conditions—mental
illnesses, substance abuse, trauma-related symptoms, developmental problems,
brain injury, and even general medical conditions—whom the service
system had failed and who wound up in jail. A series of minor offenses that
could have been handled outside the criminal justice system instead led to
long periods of incarceration. It is particularly distressing to know that for
many of these individuals, simple and inexpensive interventions by a
well-organized local care system could have prevented these tragic
Among the reform ideas that have evolved in recent years are programs that
aim to divert people with mental illness from jail and prison before they
become entangled in the legal system.
One such program—for homeless individuals in Miami-Dade County,
Fla.—was reported on by Rafael Rivas-Vazquez, Psy.D., and colleagues in
the June Psychiatric Services. They found that the program, which
sends eligible arrestees to "relationship-based care," resulted in
a "highly significant reduction" in arrest rates, compared with
the arrest rates for the same people in the year before their latest arrest.
Low rearrest rates correlated with length of time in the diversion program and
the number of "psychiatric contacts" they had, among other
The Rivas-Vazquez study is an example of the data-collection efforts on
jail diversion for people with mental illness promoted by the Substance Abuse
and Mental Health Services Administration.
Another approach promoted by federal mental health officials has been the
development of innovative tactics and training for police to use in situations
involving people with mental illness to avoid unnecessary arrests and violent
escalations of incidents.
A study in the same issue examined correlations between the number of
officers trained in Crisis Intervention Teams (CITs)—which focus on
deescalating confrontations with people in a psychiatric crisis—and the
number of responses by Special Weapons and Tactics (SWAT) teams.
The study, which was conducted in Atlanta, undermined the theory that SWAT
team use would decline when CITs were available, as the researchers found no
decline in SWAT team activity in the city as the number of CIT-trained
officers grew. However, the authors noted that a larger multisite study might
get a different result because the relatively small number of SWAT calls in
their city related to a psychiatric crisis made identifying subtle changes in
"Further research is needed to explore the relationship between CIT
and SWAT, particularly in light of the increasing number of publicized cases
in which individuals with mental illness have either been injured or killed
during SWAT interventions," wrote Michael Compton, M.D., M.P.H., and
Another study in Psychiatric Services examined participants in a
forensic assertive community treatment (FACT) program, which aims to prevent
criminal recidivism and identify predictors of future arrest. The study found
that although 64 percent of participants were not rearrested during the
treatment program, some significant risk factors for recidivism among those
who were arrested included a history of arrests for violent crimes before
treatment, eviction from residential placement during treatment, and the
presence of antisocial traits.
Identifying the extent to which youth with mental illness are
over-represented in the criminal justice system was the focus of another
Psychiatric Services study. Niranjan Karnik, M.D., Ph.D., and her
colleagues used SCID interviews of 790 youths incarcerated for at least nine
months in the California Division of Juvenile Justice and determined that 88
percent of boys and 92 percent of girls had a psychiatric disorder. More than
80 percent of the sample met criteria for some type of substance use
The authors hope that their findings will influence incarceration policy in
"Juvenile-detention facilities must evaluate patients for these
disorders and incorporate adequate treatment into the rehabilitation plan for
their wards," wrote Karnik and colleagues.